Maternal Depressive Symptoms at 2 to 4 Months Post Partum and Early Parenting Practices

Supportive counselling by public health nurses for women with postpartum depression

AIM

This paper is a report of a study examining the effect of supportive counselling by public health nurses on postpartum depression.

BACKGROUND

Depression is a common condition following childbirth and may have negative consequences for the child's development, the woman's health and the relationship between the parents. Psychological intervention is a treatment alternative to biological treatment options and may prevent longer-term postpartum depression.

METHOD

The study was designed as a pragmatic trial. The study population comprised postpartum women, residing in two Norwegian municipalities, who had delivered a live-born child between June 2005 and December 2006. A total of 228 women were included in the study: 64 in the comparison municipality and 164 in the experimental municipality. Public health nurses (26) in the experimental municipality were trained in identifying postpartum depression and in providing supportive counselling. Pre-tests were conducted using the Edinburgh Postnatal Depression Scale at 6 weeks postpartum. Post-tests using the same Scale were performed at 3 and 6 months postpartum.

RESULTS

The depression score decreased statistically significantly in the experimental group compared to the comparison group both at 3 and 6 months postpartum.

CONCLUSION

Supportive counselling based on a non-directive counselling method provided by public health nurses is an effective treatment method for postpartum depression. Further research is required to assess the mothers' evaluation of the treatment and appraise methods used for management of postpartum depression in primary health care.

Maternal postnatal depression and child growth: a European cohort study

Background

Previous studies have reported postpartum depression to be associated with both positive and negative effects on early infant growth. This study examined the hypothesis that maternal postnatal depression may be a risk factor for later child growth faltering or overweight.

Methods

A total of 929 women and their children participating in a European multicenter study were included at a median age of 14 days. Mothers completed the Edinburgh postnatal depression scale (EPDS) at 2, 3 and 6 months after delivery. EPDS scores of 13 and above at any time were defined as maternal depression. Weight, length, triceps and subscapular skinfold thicknesses were measured, and body mass index (BMI) were calculated when the children were two years old and converted to standard deviation scores based on the WHO Multicentre Growth Reference Study (MGRS).

Results

Z-scores for weight-for-length at inclusion of infants of mothers with high EPDS scores (-0.55, SD 0.74) were lower than of those with normal scores (-0.36, SD 0.74; p = 0.013). BMI at age 24 months did not differ in the high (16.3 kg/m2, SD 1.3) and in the normal EPDS groups (16.2 kg/m2, SD 1.3; p = 0.48). All other anthropometric indices also did not differ between groups, with no change by multivariate adjustment.

Conclusions

We conclude that a high maternal postnatal depression score does not have any major effects on offspring growth in high income countries.

Postpartum depression effects on early interactions, parenting, and safety practices: a review

In this paper studies are reviewed from the last decade on postpartum depression effects on early interactions, parenting, safety practices and on early interventions. The interaction disturbances of depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups and, include less sensitivity of the mothers and responsivity of the infants. Several caregiving activities also appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines and well-child visits, vaccinations and safety practices. These data highlight the need for universal screening of maternal and paternal depression during the postpartum period. Early interventions reviewed here include psychotherapy and interaction coaching for the mothers, and infant massage for their infants.

Physical activity prior to and during pregnancy and risk of postpartum depressive symptoms

OBJECTIVE

To examine the relationship between physical activity before and during the last trimester of pregnancy and postpartum depressive symptoms.

DESIGN

Secondary analysis of data from the 2004 and 2005 Pregnancy Risk Assessment Monitoring System.

SETTINGS

Mailed questionnaire or telephone interview of new mothers in North Carolina.

PATIENTS/PARTICIPANTS

Female residents of North Carolina, ages 18 to 45 (n=2,169), who had given birth to a live infant in the past 2 to 6 months.

METHODS

Information on physical activity and depressive symptoms was self-reported. Logistic regression was used to examine the physical activity-depressive symptom associations while controlling for confounding variables.

RESULTS

After adjustment for confounders, there were no statistically significant associations between being physically active before and/or during pregnancy and feeling depressed or "down." However, participants who were physically active both prepregnancy and during the last trimester had decreased odds of having little interest or pleasure compared with participants who were not physically active, after adjustment for age and marital status (odds ratio =0.66, 95% confidence interval: 0.49, 0.87).

CONCLUSION

Although regular physical activity is recommended for healthy women during pregnancy, additional studies are needed to investigate the physical activity-depressive symptoms association. If confirmed in other studies, physical activity may be an additional option for women who want to ease postpartum depressive symptoms.

Mental illness as a risk factor for uninsurance among mothers of infants

The objective of this study was to assess the extent to which maternal prenatal mental illness is associated with mothers' health insurance status 12-18 months after giving birth. The sample consisted of 2,956 urban, mostly unwed, mothers who gave birth in 20 large U.S. cities between 1998 and 2000 and participated in the Fragile Families and Child Wellbeing birth cohort study. Multinomial logistic regression models were used to assess associations between maternal prenatal mental illness and whether the mother had private, public, or no insurance one year after the birth. Covariates included the mother's and child's physical health status, the father's physical and mental health status, and numerous other maternal, paternal, and family characteristics. Potential mediating factors were explored. The results showed that mothers with prenatal diagnosed mental illness were almost half as likely as those without mental illness diagnoses to have private insurance (vs. no insurance) one year after the birth. Among mothers who did not have a subsequent pregnancy, those with prenatal mental illness were less likely than those without mental illness diagnoses to have public insurance than to be uninsured. Screening positive for depression or anxiety at one year decreased the likelihood that the mother had either type of insurance. Policies to improve private mental health care coverage and public mental health services among mothers with young children may yield both private and social benefits. Encounters with the health care and social service systems experienced by pregnant and postpartum women present opportunities for connecting mothers to needed mental health services and facilitating their maintenance of health insurance.

Screening for maternal depression in primary care pediatrics

PURPOSE OF REVIEW

An estimated 10-20% of mothers suffer from postpartum depression. Given its profound impact on both mother and infant and the availability of effective interventions, pediatricians can improve identification and referral of mothers with postpartum depression by screening regularly during well child visits. The purpose of this paper is to review and assess recently developed screening tools.

RECENT FINDINGS

Since the development of the Edinburgh Postnatal Depression Scale in 1987, several shorter screening tools have been introduced. Although further innovation to optimize appropriate identification of postpartum depression is critical, these brief tools have been shown to be useful in improving pediatrician recognition of depression in mothers and referral to psychiatric specialists.

SUMMARY

Recently developed brief screening tools are recommended for routine use by pediatricians during well child visits to identify mothers who need additional evaluation for depression. Screening should be conducted repeatedly during the first year of child rearing as symptoms of postpartum depression may appear at any time and its progression may help differentiate between mild and more severe forms of depression. Pediatricians can also provide appropriate follow-up of the family.

The effect of brief alcohol intervention on postpartum depression

PURPOSE

To report on secondary results from the Healthy Moms Study, a clinical trial to test the efficacy of brief intervention on reducing alcohol use and alcohol-related harms in postpartum women.

STUDY DESIGN AND METHODS

Data from a randomized clinical trial conducted between 2002 and 2005 with a sample of Wisconsin women was analyzed. This report presents comparison data on depressive symptomatology between postpartum women drinking above recommended levels who received a brief alcohol intervention and those who received no intervention.

RESULTS

At 6-month follow-up, there was a significant reduction in mean depression scores compared to baseline in the women who received the alcohol intervention (p < .001). There was no significant reduction in depressive symptomatology in the control group. Mean level of depression at 6 months was significantly predicted by baseline depression and the alcohol intervention (p = .018). Alcohol use at either baseline or follow-up was not a predictive factor in determining mean depressive symptomatology.

CLINICAL IMPLICATIONS

The results of the Healthy Moms Study support the importance of both alcohol and depression screening during the postpartum period. Brief alcohol intervention during this time may also positively affect depressive symptomatology.

Household food security is associated with growth of infants and young children in rural Bangladesh

Objective

Despite a strong relationship between household food security and the health and nutritional status of adults and older children, the association of household food security with the growth of infants and young children has not been adequately studied, particularly in developing countries. We examined the association between household food security and subsequent growth of infants and young children in rural Bangladesh.

Design

We followed 1343 children from birth to 24 months of age who were born in the Maternal and Infant Nutrition Intervention in Matlab (MINIMat) study in rural Bangladesh. A food security scale was created from data collected on household food security from the mothers during pregnancy. Data on weight and length were collected monthly in the first year and quarterly in the second year of life. Anthropometric indices were calculated relative to the 2006 WHO child growth standards. Growth trajectories were modelled using multilevel models for change controlling for possible confounders.

Results

Household food security was associated (P < 0·05) with greater subsequent weight and length gain in this cohort. Attained weight, length and anthropometric indices from birth to 24 months were higher (P < 0·001) among those who were in food-secure households. Proportions of underweight and stunting were significantly (P < 0·05) lower in food-secure households.

Conclusions

These results suggest that household food security is a determinant of child growth in rural Bangladesh, and that it may be necessary to ensure food security of these poor rural households to prevent highly prevalent undernutrition in this population and in similar settings elsewhere in the world.

Prevalence of postpartum depression in two municipalities in Norway

The objectives of this study were (i) to describe the prevalence of postpartum depression (PPD) in two Norwegian municipalities and (ii) to investigate whether mothers' age and parity are related to the development of PPD. A total of 2227 women, 437 from M1 and 1790 from M2 participated in the study. Mothers who had given birth between 1 May, 2005 and 31 December, 2006 completed The Edinburgh Postnatal Depression Scale (EPDS) at well baby clinics 6 weeks after delivery. The prevalence of PPD (EPDS >or= 10) was 10.1%. However, there was a significant difference between the municipalities, with a prevalence of 14.4% in M1 and 9% in M2. Primiparous mothers showed a higher prevalence than multiparous mothers did, and the oldest mothers (36 years and over) showed the highest prevalence. PPD is an issue of importance in Norway, as in many other countries. Public health services should be aware of the higher risk of PPD among primiparous mothers and especially among older primiparous mothers. A small difference in the information provided by nurses to the mothers in the two groups at the home visit 2 weeks postpartum may have produced a significant difference in the prevalence of PPD. The findings may have implications for service delivery in public health.

Parental depressive symptoms: relationship to child development, parenting, health, and results on parent-reported screening tools

OBJECTIVE

To determine whether parents with depressive symptoms can accurately complete parent-reported developmental screens, and to explore effects of parental depressive symptoms on perceptions of children's health and parenting behaviors.

STUDY DESIGN

A total of 382 parent-child (ages 0 to 2 years) dyads from pediatric sites across 17 U.S. states were evaluated with the directly administered and parent-reported Brigance Infant Toddler Screen, the Brigance Parent-Child Interactions Scale, a child development and health rating scale, and a caretaker depression screen. Groups were compared by parental status by depression screening.

RESULTS

Fifteen percent of parents had positive scores on screening for depression. Parents with a positive screen result for depression were twice as likely to rate their children as below average or average and to perceive health problems in their children. Their children were 1.7 times more likely to perform below Brigance Screen cutoffs. Parents with a positive screen result for depression were as accurate as parents with a negative screen result for depression in identifying delayed or average development but were significantly less likely to rate their above-average children as such and reported fewer positive parenting practices.

CONCLUSION

Parents with a positive depression screen result were as accurate in identifying developmental problems as parents with a negative depression screen result. Parental depressive symptoms are negatively associated with parenting behaviors, parental perspective on health and development, and child outcomes, which supports screening for depression and intervening promptly.

Obstetric care provider engagement in a perinatal depression screening program

To investigate obstetric care provider attitudes toward perinatal depression screening and factors associated with variable screening rates. Provider attitudes about depression screening were investigated via structured interviews (open-ended and rating scale questions) and analyzed using qualitative content analysis. Most providers (86%) found screening effective at identifying women at risk for perinatal depression (average rating of 8.7 on 10-point analog scale). However, 95% overestimated their own screening rates and 67% inaccurately thought they achieved universal screening. Providers not directly involved in their office-based screening process demonstrated lower average screening rates (37%) than those who maintained active involvement (59%; p = 0.07). Obstetric care providers support perinatal depression screening in the context of a program that assumes responsibility for processing screens, conducts assessments of at-risk women and provides referrals to mental health professionals. Provider participation in screening and tying screening to routine obstetric outpatient activities such as glucose tolerance testing are associated with higher screening rates.

Patterns of distress in African-American mothers of preterm infants

OBJECTIVE

To examine inter-relationships among stress due to infant appearance and behavior in the neonatal intensive care unit (NICU), parental role alteration stress in the NICU, depressive symptoms, state anxiety, posttraumatic stress symptoms, and daily hassles exhibited by African-American mothers of preterm infants and to determine whether there were subgroups of mothers based on patterns of psychological distress.

METHOD

One hundred seventy-seven African-American mothers completed questionnaires on their psychological distress at enrollment during infant hospitalization and 2, 6, 12, 18, and 24 months after term.

RESULTS

Psychological distress measures were intercorrelated. There were four latent classes of mothers: the low distress class with low scores on all measures; the high NICU-related stress class with high infant appearance and parental role stress and moderate scores on other measures; the high depressive symptoms class with high depressive symptoms and state anxiety and moderately elevated scores on NICU-related stress and posttraumatic stress symptoms; the extreme distress class with the highest means on all measures. Infants in the high stress class were sicker than infants in the other classes. The extreme distress class mothers averaged the lowest educational level. The classes differed on distress measures, worry about the child, and parenting stress through 24 months with the extreme distress class having the highest values.

CONCLUSION

Although different types of maternal psychological distress were substantially related, there were distinct subgroups of mothers that were identifiable in the NICU. Moreover, these subgroups continued to differ on trajectories of distress and on their perceptions of the infants and parenting through 24 months after term.

Universal screening for postpartum depression: an inquiry into provider attitudes and practice

OBJECTIVE

This study evaluated the use of the Edinburgh Postnatal Depression Scale (EPDS) for detection of postpartum depression (PPD) in an academic medical center outpatient population and assessed knowledge and attitudes of obstetric providers regarding detection and treatment of PPD.

STUDY DESIGN

A total of 512 charts were reviewed for demographic, medical, and psychiatric information. Also, a validated e-mail survey was sent to University of North Carolina obstetrical providers (n = 47).

RESULTS

Our chart review revealed that providers documented the EPDS score in 39% of visits and counseled patients on their score and/or depression in 35% of visits. The survey results show that all respondents agree that they are responsible for screening for PPD, and 94% are confident in diagnosing PPD.

CONCLUSION

The majority of obstetric providers are not documenting the EPDS in their postpartum assessment, yet they feel responsible for and confident in screening for postpartum depression.

Parental mental health, education, age at childbirth and child development from six to 18 months

AIM

To investigate the effect six-month parental mental health has on children's six and 18-month development. Parental covariates of age and education were also analysed.

METHODS

Through a national random selection, 21 648 babies were selected. Parental self perceived overall mental health was measured using 36-Item Short Form Health Survey (SF-36) and children's development using the Taiwan Birth Cohort Study (TBCS) instrument which measures gross motor, fine motor, language and social dimensions of children's development.

RESULTS

Both multiple linear regression and structural equation modeling showed that when the covariates of parental education and age at childbirth were added, the effect parental mental health has on children's development decreases. Additionally, maternal mental health had a more persistent and pervasive effect than paternal mental health. Father's mental health at six months had a delayed effect, in that its influence was seen only with children's development at 18 months. Of the three factors of parental mental health, education and age at childbirth, parental education had the most pervasive and persistent effect on children's development.

CONCLUSION

Although parental mental health has an effect on children's development, parental education and age at childbirth are vital confounding factors, which should be considered in future studies. Clinical health care providers should provide childcare resources and instructions to younger, less educated and parents with mental symptoms.

The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review

CONTEXT

The negative health consequences of postpartum depression are well documented, as are the benefits of breastfeeding. Despite the detailed research related to these maternal and infant health outcomes, the relationship between maternal mood and breastfeeding remains equivocal.

OBJECTIVE

A qualitative systematic review was conducted to examine the relationship between postpartum depressive symptomatology and infant-feeding outcomes.

METHODS

We performed electronic searchers in Medline (1966-2007), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-2007), and Embase (1980-2007) by using specific key words. A hand search of selected specialist journals and reference lists of articles obtained was then conducted. Seventy-five articles were reviewed, of which 49 specifically provided data to be extracted related to postpartum depressive symptomatology and infant-feeding outcomes. Both authors independently extracted data including study design, participants (number and characteristics), and results.

RESULTS

The results from this review suggest that women with depressive symptomatology in the early postpartum period may be at increased risk for negative infant-feeding outcomes including decreased breastfeeding duration, increased breastfeeding difficulties, and decreased levels of breastfeeding self-efficacy. There is also beginning evidence to suggest that depressed women may be less likely to initiate breastfeeding and do so exclusively.

CONCLUSIONS

Depressive symptomatology in the postpartum period negatively influences infant-feeding outcomes. These findings have important clinical implications and support the need for early identification and treatment of women with depressive symptomatology. However, strategies to address help-seeking barriers are needed if women are to receive appropriate and timely treatment. Research to determine effective interventions to support depressed breastfeeding women is warranted.

Short-term outcomes of mothers and newborn infants with comorbid psychiatric disorders and drug dependency

OBJECTIVES

The aim of the present study was to determine the characteristics and short-term outcomes of mother-infant pairs with comorbid drug dependency and psychiatric disorders.

METHODS

A population-based retrospective chart review was carried out of 879 drug-dependent mother and infant pairs in New South Wales (NSW) and the Australian Capital Territory (ACT) who delivered between 1 January and 31 December 2004.

RESULTS

Psychiatric comorbidity (dual diagnosis, DD) was identified in 396 (45%) of the 879 drug-dependent women. DSM-IV depression (79%), followed by anxiety (20%), was most prevalent. DD women were more likely to use amphetamines (29% vs 18%, p < 0.05), less likely to use opiates (42% vs 51%, p < 0.05) and to have had no antenatal care (24% vs 8%, p < 0.05). They also had more previous pregnancies (4, range = 2-5 vs 3, range = 2-5, p < 0.05) and domestic violence (29% vs 14%, p < 0.05) was more common. DD infants were less likely to be admitted to a nursery (47% vs 55%, p < 0.05). Withdrawal scores were similar (maximum median Finnegan scores = 4 (interquartile range = 3-8) vs 10 (interquartile range = 7-12, p = 0.30) but fewer needed withdrawal medication (19% vs 27%, p < 0.05). Maternal psychotropic agents did not worsen the severity of neonatal withdrawal.

CONCLUSIONS

Psychiatric comorbidity, especially depression, is common and affects almost half of drug-using mothers. Antenatal care, drug use and social outcomes are worse for DD mothers and their infants. It is recommended that all drug-using women be assessed antenatally for psychosocial disorders so that timely mental health intervention can be offered, if required.

Multiple births are a risk factor for postpartum maternal depressive symptoms

OBJECTIVE

The purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms measured 9 months after delivery.

METHODS

Data were derived from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal study of a nationally representative sample of children born in 2001. Depressive symptoms were measured at 9 months by using an abbreviated version of the Center for Epidemiologic Studies Depression Scale. Logistic regression analyses were conducted to study the association between multiple births and maternal depressive symptoms, with adjustment for demographic and household socioeconomic characteristics and maternal history of mental health problems. A total of 8069 mothers were included for analyses.

RESULTS

The prevalence of moderate/severe depressive symptoms at 9 months after delivery was estimated to be 16.0% and 19.0% among mothers of singletons and multiple births, respectively. Only 27.0% of women who had moderate/severe depressive symptoms reported talking about emotional or psychological problems with a mental health specialist or a general medical provider within the 12 months before the interview. The proportions of women with depressive symptoms who were receiving mental health services did not vary according to plurality status.

CONCLUSIONS

Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons. Greater attention is needed in pediatric settings to address maternal depression in families with multiple births.

Modifiable factors associated with changes in postpartum depressive symptoms

Up to 50% of mothers report postpartum depressive symptoms yet providers do a poor job predicting and preventing their occurrence. Our goal was to identify modifiable factors (situational triggers and buffers) associated with postpartum depressive symptoms. Observational prospective cohort telephone study of 563 mothers interviewed at 2 weeks and 6 months postpartum. Mothers reported on demographic factors, physical and emotional symptoms, daily function, infant behaviors, social support, and skills in managing infant and household. Mothers were categorized into four groups based on the presence of depressive symptoms at 2 weeks and at 6 months postpartum: never, always, late onset, and remission groups. Fifty-two percent did not have depressive symptoms at 2 weeks or at 6 months (never group), 14% had symptoms at both time points (always group), 10% had late onset, and 24% had early onset of symptoms with remission. As compared with women in the never group, women in the always and late onset groups had high-risk characteristics (e.g., past history of depression), more situational triggers (e.g., physical symptoms), and less robust social and personal buffers (i.e., social support and self-efficacy). As compared with the never group, mothers in the remission group had more situational triggers and fewer buffers initially. Changes in situational triggers and buffers were different for the four groups and were correlated with group membership. Situational triggers such as physical symptoms and infant colic, and low levels of social support and self-efficacy in managing situational demands are associated with postpartum depressive symptoms. Further research is needed to investigate whether providing education about the physical consequences of childbirth, providing social support, and teaching skills to enhance self-efficacy will reduce the incidence of postpartum symptoms of depression.

Screening for maternal depression in the neonatal ICU

Postpartum depression is common in women with infants in the neonatal ICU. Maternal depression can affect infant health and development adversely. A screening program for depression in the neonatal ICU could identify women who have depressive symptoms and facilitate their referral for follow-up services.

Healthy Steps: a systematic review of a preventive practice-based model of pediatric care

The preventive role of anticipatory guidance in pediatric practice has gained increasing importance over the last two decades, resulting in the development of competing models of practice-based care. Our goal was to systematically evaluate and summarize the literature pertaining to the Healthy Steps Program for Young Children, a widely cited and utilized preventive model of care and anticipatory guidance, Medline and the bibliographies of review articles for relevant studies were searched using the keywords: Healthy Steps, preventive care, pediatric practice and others. Other sources included references of retrieved publications, review articles, and books; government documents; and Internet sources. Relevant sources were selected on the basis of their empirical evaluation of some component of care (e.g., child outcomes, parent outcomes, quality of care). From 21 identified articles, 13 met the inclusion criteria of empirical evaluation. These evaluations were summarized and compared. Results indicated that the Healthy Steps program has been rigorously evaluated and shown to be effective in preventing negative child and parent outcomes and enhancing positive outcomes. Despite limited information concerning cost effectiveness, the Healthy Steps Program provides clear benefit through early screening, family-centered care, and evidence-based anticipatory guidance. It is recommended that the Healthy Steps program be more widely disseminated to relevant stakeholders, and further enhanced by improved linguistic and cultural sensitivity and long term evaluation of cost effectiveness.

Trajectories of maternal depressive symptoms over her child's life span: relation to adrenocortical, cardiovascular, and emotional functioning in children

Maternal depression has a number of adverse effects on children. In the present study, maternal depressive symptoms were assessed (using the Center for Epidemiological Studies Depression Scale) when their child was 3 months, 6 months, 1 year, 2 years, 4.25 years, 6 years, 7 years, 8 years, and 10 years of age. At 9.5 years of age, children's (94 females, 82 males) depressive symptoms as well as cardiovascular and cortisol levels during baseline and two psychologically stressful tasks were measured. Using multilevel modeling, maternal depressive symptom trajectories were considered in relation to their child's adrenocortical and cardiovascular responses to acute stress. Our goal was to determine maternal depressive symptom trajectories for children with elevated cardiovascular and cortisol reactivity to acute stress and elevated depressive symptoms. In general, those mothers with chronically elevated depressive symptoms over their child's life span had children with lower initial cortisol, higher cardiac output and stroke volume in response to acute stress, lower vascular resistance during acute stress tasks, and significantly more depressive symptoms at 9.5 years of age. These results are discussed in the context of established associations among hypothalamic-pituitary-adrenal axis dysregulation, depression, and cardiovascular disease.

The influence of psychological factors on breastfeeding duration

AIM

This paper reports on a study examining the relationship between women's psychological characteristics and breastfeeding duration, after controlling for socio-demographic factors.

BACKGROUND

The literature suggests that psychological factors may influence breastfeeding behaviour, but studies are few. Existing evidence and the results of phase 1 of our study were used to construct a list of psychological factors, which were tested for their association with breastfeeding duration in the current design.

METHOD

Participants were postnatal inpatients in one of two regional hospitals between October and December 2005 and they completed the initial questionnaire within 14 days of giving birth (n = 375). Infant feeding method at 6 months and the timing of introduction of other food(s), where relevant, were ascertained by telephone interview.

FINDINGS

Forty-four per cent of the sample showed signs of postnatal distress in the 14 days following the birth. Breastfeeding duration was statistically significantly associated with psychological factors including dispositional optimism, breastfeeding self-efficacy, faith in breastmilk, breastfeeding expectations, anxiety, planned duration of breastfeeding and the time of the infant feeding decision. As a set, these psychological factors were more predictive of breastfeeding duration than was the set of socio-demographic characteristics. The duration of any breastfeeding was uniquely predicted by faith in breastmilk, planned breastfeeding duration and breastfeeding self-efficacy.

CONCLUSION

This increased knowledge of the factors influencing breastfeeding will assist in identifying women at risk of early weaning and in constructing programmes capable of increasing the length of time for which women breastfeed.

Functional status outcomes in mothers with and without postpartum depression

Our objective was to compare functional status between women with and without postpartum depression (PPD). A two-group cross-sectional design compared functional status between 23 women with and 23 women without PPD. Participants were 6 to 26 weeks postpartum and from obstetric practices in the northeastern United States. Structured clinical interviews were used to establish diagnoses of PPD. Participants were matched on type of delivery, weeks postpartum, and parity. Participants compared current functioning to prepregnancy functioning using the Inventory of Functional Status After Childbirth. The Postpartum Depression Screening Scale was used to measure PPD severity. Hierarchical multiple and logistic regression models were used to analyze data. We found that after controlling for infant gender, number of nighttime infant awakenings, and income, PPD predicted lower personal (P < .001), household (P < .05), and social functioning (P < .001), but no difference in infant care. Women with PPD were 12 times less likely to achieve prepregnancy functional levels. We conclude that interventions are needed to address household, social, and personal functioning in women with PPD. Clinicians may find functional assessment is a useful adjunct and a less threatening way to screen and monitor treatment for PPD.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: does a directed interview improve detection rates compared with the standard self-completed questionnaire?

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression. It was postulated that screening utilizing the EPDS in a directed interview would increase the detection rate compared with a self-completed EPDS in an indigent population.

OBJECTIVE

To compare the results of a self-completed EPDS with those of a directed interview utilizing the EPDS in the identification of patients at increased risk for postpartum depression.

METHODS

All patients undergoing a 6-week postpartum evaluation in the obstetric clinic at a community teaching hospital between November 1, 2003 and March 31, 2004 were screened for postpartum depression using the self-completed EPDS. This was followed by a directed interview, which consisted of a verbally administered EPDS by a social worker blinded to the results of the self-completed EPDS. A positive screen was defined as an EPDS score of > or =12 by either method. The number of patients with a positive screen to either the self-completed EPDS, the directed interview EPDS, or both were recorded. The two techniques were compared by the McNemar Chi-square test. The self-completed and directed interview EPDS scores were compared by Pearson's correlation coefficient to examine differences in screening techniques. Demographic data and characteristics in each group were examined.

RESULTS

Among the 134 patients evaluated, 24 (17.9%) screened positively for being at an increased risk of having postpartum depression. The self-completed EPDS and the directed interview EPDS screening detection rates were not different, identifying 23 (17.2%) and 22 (16.4%) patients, respectively (p = 1.0). The use of the self-completed EPDS and the directed interview EPDS in parallel detected one additional subject (0.7%; p = 0.99). The self-completed EPDS and directed interview EPDS scores correlated significantly (r = 0.94; p = 0.01). The demographics and characteristics of patients with a positive screen were not different from those with a negative screen.

CONCLUSIONS

The self-completed EPDS and directed interview EPDS are equivalent screening techniques for postpartum depression. There is no evidence to suggest that parallel screening improves detection. Either technique should be incorporated into the postpartum visit to screen for postpartum depression.

Insomniac children maternal sleep and mood in São Paulo and Barcelona

OBJECTIVE

To evaluate sleep characteristics verifying for the presence of depressive symptoms in mothers of insomniac children living in São Paulo (Brazil) and Barcelona (Spain).

METHOD

Forty-six mothers were evaluated, 37 from São Paulo and nine from Barcelona, their ages varying from 19 to 44, and their children; otherwise healthy but with complaints of insomnia, their age varying from three to 33 months. The mothers' sleep quality was rated by the Pittsburgh Sleep Quality Index (PSQI), and the Beck Depression Inventory (BDI).

RESULTS

91.30% of mothers reported poor sleep by PSQI standards. Regarding signs and symptoms of depression, 69.56% of all mothers in this sample showed them. Direct correlation between São Paulo mothers PSQI and BDI was found and also between the child's age and BDI.

CONCLUSION

The mothers' poor sleep was related to mood changes with symptoms of depression presenting similar results in both cities.

A case study of postpartum depression & altered maternal-newborn attachment

This article presents a case study of a new mother experiencing postpartum depression and altered attachment with her newborn. Theories related to postpartum depression and maternal-newborn attachment are reviewed, and evidenced-based strategies for care are discussed in the context of the case.

Support from advisors on child rearing for alleviating maternal anxiety and depressive symptoms among Japanese women

BACKGROUND

Accumulating evidence suggests that social support is an important factor with regard to maternal psychological distress. The associations between the contextual factors in terms of social support and the risk of maternal psychological distress have not been adequately studied in Japan. The objective of this study was to examine the association of the presence of advisors on child rearing with maternal anxiety and depressive symptoms among Japanese women at 2 time points after childbirth.

METHODS

A self-administered questionnaire that included items regarding the conditions of child rearing and a scale to estimate psychological distress was delivered to 2657 mothers when their infants were 3-4 months and 9-10 months old in 2004-2005. Multivariate logistic regression analysis was conducted for the statistical analyses.

RESULTS

From the multivariate odds ratio, an environment with a few close advisors on child rearing was associated with the risks of maternal anxiety and depressive symptoms at 3-4 months and 9-10 months. The presence of few professional advisors on child rearing was also related to the risk of maternal depressive symptoms at the 2 time periods. The companionship of other child-rearing individuals was related to depressive symptoms at 9-10 months.

CONCLUSION

An environment without advisors on child rearing was associated with maternal psychological distress. A similarity between the observations at the 2 time points was that the presence of personal and professional advisors was related to maternal anxiety and/or depressive symptoms. It was noted that the need for other child-rearing companions increases as the child grows older.

Screening for postpartum depression in a rural community

Postpartum depression is a serious mental health issue affecting as many as 10-15% of families during the postpartum period. The current study discusses implementation of a screening protocol for postpartum depression in a rural community health setting with a sample of 498 primarily minority women utilizing the Postpartum Depression Screening Scale. Results indicate that 22.5% of the sample population demonstrate some symptoms of postpartum depression, with Hispanic women demonstrating less symptoms than other minority groups. Results also indicate that variables such as race, feeding method and history of depression impact scale scores.

Maternal symptoms of stress, depression, and anxiety are related to nonresponsive feeding styles in a statewide sample of WIC participants

Parenting, including nonresponsive feeding styles, has been related to under- or overweight among young children. The relationship between maternal mental health and feeding styles has not been examined. We hypothesized that mothers who report more symptoms of stress, depression, or anxiety report less responsive (e.g. more controlling, indulgent, and uninvolved) feeding styles than mothers who report fewer symptoms of stress, depression, or anxiety. Our analyses included 702 mother-infant pairs from a statewide sample of Special Supplemental Nutrition Program for Women, Infants, and Children mothers. We assessed maternal mental health and feeding styles by a telephone survey. After adjusting for potential confounding variables, maternal stress symptomatology was significantly associated with forceful (beta = 0.03; 95% CI = 0.02, 0.05) and uninvolved (OR = 1.4; 95% CI = 1.1, 1.7) feeding style scores, maternal depression symptomatology was significantly associated with forceful (beta = 0.03; 95% CI = 0.004, 0.05), indulgent (beta = 0.03; 95% CI = 0.004, 0.06), and uninvolved (OR = 1.5; 95% CI = 1.001, 2.2) feeding styles scores, and maternal anxiety symptomatology was significantly related to restrictive (beta = 0.11; 95% CI = 0.01, 0.21), forceful (beta = 0.04; 95% CI = 0.02, 0.06), and uninvolved (OR = 1.4; 95% CI = 1.01, 1.9) feeding style scores. Among mothers who perceived their infant as temperamentally fussy, there was a significant positive relationship between restrictive feeding styles scores and 3 indices of maternal mental health (stress, beta = 0.18; 95% CI = 0.07, 0.28; depression, beta = 0.21; 95% CI = 0.04, 0.38; and cumulative mental health symptomatology, beta = 0.29; 95% CI = 0.10, 0.48). Mothers who report stress, depression, or anxiety symptoms are at risk for nonresponsive feeding styles. These findings provide support for broadening the focus of existing child nutrition programs to include strategies that recognize how issues of maternal mental health can affect feeding styles.

Birth during autumn is a risk for adolescent self-mutilative behavior

BACKGROUND

A season of birth tendency has been shown for several psychiatric disorders and suicidal behavior. Our aim was to examine the association between season of birth and self-mutilative behavior (SMB) among adolescent psychiatric inpatients.

METHODS

The study sample consisted of 508 (40.9% males) 12- to 17-year-old adolescents consecutively admitted to the Department of Psychiatry of Oulu University Hospital, Finland, between April 2001 and May 2006. The birth month of each adolescent was categorized into one of the four seasons: spring (March-May), summer (June-August), autumn (September-November) or winter (December-February). The information on SMB was based on the K-SADS-PL interview, which included an item on nonsuicidal physical self-damaging acts without intent to die. A total of 144 adolescents (27 males, 117 females) met the criteria for SMB. The association between season of birth and SMB was assessed with a logistic regression analysis after controlling for each adolescent's age, previous suicide attempts and DSM-IV-diagnosed psychiatric disorders.

RESULTS

The monthly distribution of births of adolescents with SMB differed statistically significantly from that observed in the general population of the same age. An association between season of birth and SMB was seen in girls, but not in boys. The likelihood for SMB was significantly increased (adjusted OR 2.9; 95% CI 1.4-6.2) among girls born in autumn compared to those born in winter.

CONCLUSIONS

Birth during autumn may predispose girls to SMB via dysfunctional serotonergic or other neurotransmitter systems. These findings may also be related to seasonal rhythms in parental mood and poor early care of the offspring.

Postpartum mood disorders and maternal perceptions of infant patterns in well-child follow-up visits

AIMS

The aims of this study were to evaluate the associations between postpartum depressive symptoms and maternal perceptions of infant patterns with 1-year follow-up examinations, and to assess the impacts of treatment on these perceptions.

METHODS

One hundred three mother-infant pairs were evaluated. Data on maternal reports of infant feeding, sleeping and temperament patterns were collected at each well-child visit. The Edinburgh Postpartum Depression Scale was used to assess depressive symptoms. A psychiatrist interviewed the mothers with depressive symptoms, and psychiatric treatments were administered accordingly. The associations between depressive symptoms and maternal perceptions at each visit were analyzed by taking into account the entire follow-up period.

RESULTS

Thirty-five mothers (34%) scored within the clinical range of the EPDS during the follow-up period. Mothers with elevated depressive symptoms were more inclined to report infant cry-fuss, sleeping and temperamental problems through the follow-up. Such complains on infant cry-fuss and temperament problems and maternal sleeping problems improved after treatment in compliant mothers. The dropout rate was high (58.3%) in noncompliant mothers.

CONCLUSION

Postpartum depressive symptoms may lead to negative maternal perceptions of infant patterns. Earlier management of these disorders and maternal compliance to psychiatric suggestions may provide a better care for the mother-infant pairs.

State of the Art Reviews: Intervening to Improve Outcomes for Adolescent Mothers and Their Children

Adolescent births have declined substantially in the past 15 years, especially with the increase in use of e fective contraception by young women. Longitudinal data have shown that previously identified disadvantages of early parenting for young women, particularly those from communities with high rates of poverty, may not be substantial. There are indications that higher order births carry a much greater burden than do first births to females younger than 20 years. For those interested in minimizing the burden for these young women, interventions to prevent second births are important. Studies have looked at how best to provide care to these women and infants and how to reduce rates of higher order births. These programs provide ideas on factors that can help identify those at greatest risk for second births and give models for working with young mothers to maximize career and life chances. Particular attention should be paid to contraception use, infant stimulation, school and work participation, postpartum depression, and breastfeeding when working with adolescent mothers.

Continued exposure to maternal distress in early life is associated with an increased risk of childhood asthma

RATIONALE

Evidence is emerging that exposure to maternal distress in early life plays a causal role in the development of childhood asthma.

OBJECTIVES

Because much of the data are from high-risk cohorts, we undertook a birth cohort study in a complete population of children to test this association.

METHODS

Using Manitoba, Canada's, health care and prescription databases, this longitudinal study assessed the association between maternal distress during the first year of life and onward, and asthma at age 7 in a 1995 birth cohort of 13,907 children.

MEASUREMENTS AND MAIN RESULTS

Maternal distress was defined on the basis of health care or prescription medication use for depression or anxiety. Asthma status was derived from health care and prescription records for asthma, using a definition validated by comparison to pediatric allergist diagnosis. Multiple logistic regression was used to determine the likelihood of asthma (odds ratio [OR], 95% confidence interval [95% CI]). Independent of well-known asthma risk factors, our population-based study of a non-high-risk cohort demonstrated an increased risk of childhood asthma (OR, 1.25; 95% CI, 1.01-1.55) among children exposed to continued maternal distress from birth until age 7. Exposure to maternal depression and anxiety limited to the first year of life did not have a demonstrable association with subsequent asthma. Of interest, we observed that the risk of asthma associated with continued maternal distress was increased in children living in high- versus low-income households (OR, 1.44; 95% CI, 1.12-1.85).

CONCLUSIONS

Maternal distress in early life plays a role in the development of childhood asthma, especially if it continues beyond the postpartum period.

Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers

We used the Early Childhood Longitudinal Study-Birth Cohort 9- and 24-mo surveys (n = 8693) and Structural Equation Modeling to examine direct and indirect associations between food insecurity and toddlers' overweight (weight for length), physical health, and length for age. There were significant effects of food insecurity on parental depression and parental depression in turn influenced physical health. There were also significant effects of food insecurity on parenting practices, which in turn were significantly associated with infant feeding and subsequently toddlers' overweight. There were no significant direct or indirect associations between food insecurity and toddlers' length for age. Our results show that food insecurity influences parenting, including both depression and parenting practices. Findings suggest parental depression is a stressor on parenting behavior that social policy should address to alleviate problematic child health outcomes. Findings underscore the importance of continuing and strengthening policy initiatives to ensure that families with infants and toddlers have sufficient, predictable, and reliable food supply.

Psychosomatic disorders in pregnancy

PURPOSE OF REVIEW

Common and important psychosomatic disorders in pregnancy reviewed here include perinatal depression, posttraumatic stress disorders, anxiety disorders, eating disorders, and postpartum psychosis.

RECENT FINDINGS

Research has focused on antenatal depression as postpartum depression often has onset prior to delivery. Certain psychosocial and psychological interventions can effectively prevent postnatal depression. Although the use of selective serotonin reuptake inhibitors was associated with miscarriage, preterm delivery, and fetal death, discontinuation of antidepressants also increased the relapse rate during pregnancy. Studies also show that about 8% of mothers had eating problems during their pregnancy, which increased to 19% in the postpartum period. Postpartum psychosis is an important diagnosis related to maternal death from suicide. Personal and family history of bipolar disorders are important risk factors.

SUMMARY

Recent findings highlight the importance of correct diagnosis and awareness of serious mental illness. In view of the higher rate of relapse, women should be counselled carefully regarding discontinuation of antidepressants during pregnancy. Differentiation of posttraumatic stress disorders with comorbid anxiety and depression, awareness of risk factors, and clinical features of psychosis are important in the management of psychosomatic disorders in pregnancy.

Legal and ethical considerations: risks and benefits of postpartum depression screening at well-child visits

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric provider's responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.